Thursday, 11 August 2016

Just kicking off the autumn term after some well-needed weeks of complete holiday, summing up some recent and very soon available or forthcoming work in a few different areas:

1. Conscientious objection or refusal of professionals (in health care and elsewhere)
This is an area, i have been posting about before (here, and here).

a) As I flagged earlier in one of these posts, there is one article on this topic, co-authored by myself and Morten Ebbe Juul Nielsen, entitled "The Legal Ethical Backbone of Conscientious Refusal", forthcoming in a special issue of the Cambridge Quarterly of Healthcare Ethics, now formally accepted and with a so-called "postprint" (our finally submitted manuscript after peer review) avialable for free online reading and download here and here. In short, me and Morten argues that the idea of a legal right to conscientious refusal is either incompatible with basic legal ethical principles (equal treatment, rule of law etc), or indefensible by undermining core societal values. Here's the abstract:

This
paper analyses the idea of a legal right to conscientious refusal for
health care professionals from a basic legal ethical standpoint, using
refusal to perform tasks related to legal abortion (in cases of
voluntary employment) as a case in point. The idea of a legal right to
conscientious refusal is distinguished from ideas regarding moral rights
or reasons related to conscientious refusal, and none of the latter are
found to support the notion of a legal right. Reasons for allowing some
sort of room for conscientious refusal for health care professionals
based on the importance of cultural identity and the fostering of a
critical atmosphere might provide some support, if no countervailing
factors apply. One such factor is that a legal right to health care
professionals conscientious refusal must comply with basic legal ethical
tenets regarding the rule of law and equal treatment, and this
requirement is found to create serious problems for those wishing to
defend the idea under consideration. We conclude that the notion of a
legal right to conscientious refusal for any profession is either
fundamentally incompatible with elementary legal and ethical
requirements, or implausible because it undermines the functioning of
related professional sector (healthcare) or even of society as a whole.

b) In the same post, I also mentioned a workshop on this topic at the Brocher Foundation in Geneva, which took place as planned in June. The slides to my presentation there, "All
or nothing! The legal, ethical and jurisprudential basis of legal
rights to conscientious objection of voluntarily employed professionals" (building on and somewhat extending the argument of mine and Morten's article above), are available here and here.

c) At the same workshop, a wide range of presenters with opposing views on many issues nevertheless found themselves to agree on a number of core positions, and a consensus statement is currently being drafted for speedy publication, soon to be available in an as yet unnamed professional journal.

d) The workshop organisers, Alberto Giubilini, Julian Savulescu and Sharyn Milnes, moreover invited participants to submit to a further special issue on the topic, now in the Journal of Medical Ethics. As mine and Morten's article was already placed, I wrote a brief note on the Swedish way of dealing with conscientious objection in health care, entitled "Conscientious Refusal in Healthcare: The Swedish Solution", which is now accepted for publication, and available in its "preprint" (original submitted manuscript) form for free reading and download here and here. This is the abstract:

The
Swedish solution to the legal handling of professional conscientious
refusal in health care is described. No legal right to conscientious
refusal for any profession or class of professional tasks exist in
Sweden, regardless of the religious or moral background of the
objection. The background of this can be found in strong convictions
about the importance of public service provision and related civic
duties, and ideals about rule of law, equality and non-discrimination.
Employee requests to change work tasks are handled case by case within
the frames of labour law, ensuring full voluntariness, but also employer
privilege regarding the organisations and direction of work, and duties
of public institutions to provide services. Two complicating aspects of
this solution related to the inclusion of "alternative medical" service
providers in a national health service, and professional insistence on
conscientious refusal rights to accept legalised assisted dying are
discussed. The latter is found to undermine the pragmatic reasons behind
recent attempts by pro-life groups to challenge the Swedish solution
related to legal abortion in courts.

2. The ethics of responsibility and priority-setting in shared decision-making
This is work undertaken in an ongoing research programme on the ethics of person centred care, of which I'm a part, but also linked to my work in the Gothenburg Responsibility Project. It builds further on earlier collaborative analyses by myself and Lars Sandman of the notion of so-called shared decision-making in health care. Together with Erik Gustavsson, we have an article that has just been published online in the Journal of Medical Ethics, where we penetrate the idea that increased patient involvement in and empowerment over clinical decisions would strengthen the case for the idea of holding them responsible for lack of adherence to agreed care plans (and the resulting ill-health) through a less favourable priority-setting of their health needs. We also discuss whether or not the ideas behind shared decision-making constitute an argument in favour of applying some such principle of individual responsibility for ill-health. Basically, our answer is yes to the first query and no to the second, although we also note several limitations and complications. "Preprints" of this article are available for free reading and download here and here. This is the abstract:

Given
health care resource constraints, voices are raised to hold patients
responsible for their health-choices. In parallel, there is a growing
trend towards shared decision-making, aiming to empower patients and
give them more control over health care decisions. More power and
control over decisions is usually taken to mean more responsibility for
these. The trend of shared decision-making would therefore seem to
strengthen the case for invoking individual responsibility in health
care priority setting.Objective and DesignThe
objective was to analyze whether the implementation of shared
decision-making would strengthen the argumentative support for invoking
individual responsibility in health-care priority setting, using
normative analysis.Results and ConclusionsShared
decision-making does not constitute an independent argument in favor of
employing individual responsibility since these notions rest on
different underlying values. However, these theoretical tensions do not
constitute a problem for combining these phenomena in practice. If a
health system employs shared decision-making, individual responsibility
may be used to limit resource implications of accommodating patient
preferences outside of professional standards and goals. If a health
care system employs individual responsibility, high level dynamic shared
decision-making may disarm common objections to the applicability of
individual responsibility, in
virtue of making them more likely to exercise adequate control of their
own actions. However, if communication strategies applied in the shared
decision-making are misaligned to the patient's initial capacities, the
result may be the opposite. Non high-level dynamic types of shared
decision-making would not seem to affect the applicability of individual
responsibility at all.

3. The ethics of patient education
This work, entitled "Errorthrawling
and Fringe Decision Competence: Ethical Hazards in Monitoring and
Addressing Patient Decision Capacity in Clinical Practice" utilises some material and builds partly on earlier analyses of studies of the communication and ethics of pediatric diabetes care, e.g., this one, but mostly presents fresh analytical results from my Ph.D. student Thomas Hartvigsson, who works on a thesis on the normative roles of decision competence. The article describes and discusses the ethical, emotional and professional dymamics of an extreme variant of patient education, especially risky to occur when common patient education strategies are applied to what we call "fringe decision competent patients", i.e. people who are in a grey area between obvious decision competence and incompetence. The article is still in the submission phase, so it is due to be revised a number of times, and if you have comments or suggestions, don't hesitate to contact Thomas. His email is found in the original "preprint", available for free reading and download here and here. The current abstract runs like this:

In
this article we discuss how health professionals should monitor and
safeguard patients' abilities to take part in clinical decisions and
their implementation. Such a task is essential e.g. in self-care
situation where patient is responsible for most regular care. Here,
argue that a common fact-oriented strategy of patient education in
practice tends to take the form of what we call errorthrawling.
Illustrated by empirical findings from a video study of consultation
meetings in adolescent diabetes care, we argue that this strategy both
tends to miss significant capacity weaknesses, and even undermine
capacities. In effect, this strategy for clinically monitoring and
addressing the decision capacities of patients where these are fragile
seems to be incomplete and actually hazardous. We close by suggesting
complementary and alternative strategies, and comment on how these may
actualise a need of a broadened competence of clinical health
professionals.

Being work in progress there's bound to be further news ahead on this front, which will be relayed here as it appears.

4. Hate crime philosophy and moral psychology: forthcoming 3 volume book series
Before going on holiday, me and David Brax, with whom I have been working on the philosophy of hate crime for some years now, submitted the final versions of three chapters contributing to a coming 3 volume book series published by Preager, of which we are also associate editors, entitled The Psychology of Hate Crimes as Domestic Terrorism: U.S. and Global Issues, and edited by Edward Dunbar, Amalio Blanco and Desirée A. Crèvecoeur-MacPhail. Me and David contribute two co-authoured chapters, one briefly summarising the basic philosophical issues actualised by the phenomenon of hate crime and related policy, and one on the relationship between hate crime and terrorism from a conceptual, ethical and moral psychological standpoint. In addition, I contribute a chapter on my own, where I problematise the relationship between underlying assumptions about criminal responsibility related to the moral psychological assumptions around hate criminality and crimes committed by mentally disordered offender. The series is currently in its final production stage and is due for publication in November this year.